Inspection on 09/08/05 for Bystock Court

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bystock Court 04/09/07

Bystock Court 13/09/06

Bystock Court 10/01/06

Bystock Court 06/01/05

Bystock Court 13/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Bystock Court Old Bystock Drive Exmouth Devon EX8 5EQ Lead Inspector Belinda Heginworth Unannounced 9 August 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bystock Court Address Old Bystock Drive Exmouth EX8 5EQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01395 266605 01395 222689 Devon Sheltered Homes Trust Mr Paul Rosam CRH PC Care Home providing Personal Care 41 Category(ies) of LD Learning Disability [41] registration, with number LD[E] Learning Disability over 65 [41] of places Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6th January 2005 Brief Description of the Service: Bystock Court is a registered charity. The day-to-day operation of the home is carried out by Devon Community Housing Society (DCHS). Bystock Court is registered to provide accommodation and personal care for up to 41 adults with learning disabilities. Out of the 41 rooms one is used to provide short-term care. Although the home does not admit persons over retirement age, some of the residents have continued to live there after their retirement. The main building is a large period style house set in large grounds on the outskirts of Exmouth. There are 41 single bedrooms and a range of communal areas including lounge, dining room, ballroom, craft room, games room, laundry and kitchen. There are two semi-independent units, with three ensuite bedrooms in each, a lounge and kitchen. Within the grounds are a range of buildings including a small farm, greenhouses and a paper shredding business. Residents are encouraged to participate in the running of the home and work in units according to their interests and abilities. The home also provides a range of education and leisure activities. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over five hours. The manger was present throughout the inspection. Twenty-four residents and three members of staff were consulted and their views of the home discussed. The inspector looked around parts of the buildings and grounds, and some records were read. What the service does well: What has improved since the last inspection? The manager and staff have helped residents to open their own bank accounts where benefits are paid into and fees are paid from. Some residents said they enjoyed going to the bank and paying their own bills. There is good information on what staff should do to reduce risks to residents. The manager monitors the quality of service within the home by use of satisfaction questionnaires to residents, families, staff and professionals. Assessments of all types of risks throughout the home are also in the process of being completed. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Residents benefit from good admission and assessment practices which ensure that the home is able to meet their needs. EVIDENCE: Residents spoken with were unable to remember the assessment process prior to their admission to the home. The manager completes a detailed assessment of need to ensure the home is able to meet that person’s needs prior to admission. Care management assessments are also completed. Residents are admitted to the home on a trial basis before making a decision to live there. Residents are given a contract or statement of terms and conditions on admission. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Staff are provided with written information to help them meet residents’ needs effectively and safely. EVIDENCE: Residents have copies of their care plans, which they keep in their bedroom. The plan has detailed information that highlights care and health needs clearly. Any risks associated with residents’ needs or care are assessed and the action necessary to reduce the risks are clearly explained. Residents have a dedicated person (Key worker) who is responsible for co-ordinating the care and reviewing the care plans. Residents said they attended care plan reviews regularly with their key-workers. At the review, any action needed to change residents’ care or any goals they wish to achieve is recorded. The manager intends to review this recording tool to ensure that it is clear whether the staff responsible for the action have completed the work. Staff demonstrated a good understanding of residents needs and keep daily records of events and issues for each resident. The daily records did not always reflect the care plan goals. The manager intends to review the recording systems to find ways of ensuring staff reflect goals in the daily records. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 10 Residents said they are consulted about all aspects of their lives and are supported to make decisions. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 & 16 Residents use the local and surrounding community for leisure pursuits. EVIDENCE: There are a wide range of job opportunities within Bystock Court including farming, paper shredding, gardening, catering, laundry, office work and housekeeping. Residents said they enjoyed their work. The manager is currently arranging full employment terms, conditions and pay for the residents who work at the home. Residents talked about holidays they are going on or have been on, which they helped to choose and plan. These ranged from trips to Scotland, Ireland, Newquay, Corfu and many more. Activities are arranged according to residents’ needs and preferences. These range from swimming, horse riding, pub trips, football, car boot sales, advocate groups and many more. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Residents are supported in a way they prefer and their health care needs are well met. EVIDENCE: Residents said they felt they were well taken care of and their health care needs were met. Staff demonstrated a good understanding of residents’ health care needs. Care plans provided further evidence that health care needs were assessed, monitored and met. Medication is supplied through a monitored dosage system. The pharmacy carries out six-monthly checks and provides training for the senior staff to administer medication. The manager intends to ensure that this training is appropriate and to devise a method of assessing staffs’ competencies regularly. The medication cupboards were found to be tidy and well organised. Some medication that is used when necessary (PRN), were not labelled with the name of the person it was intended. Some supplement medications, such as vitamins, that were not prescribed by a GP were not included in the individual Homely Remedy Policies. The manager intends to seek advice on how to safely monitor the use of “sedating” PRN medications. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Residents are protected from abuse, neglect and self-harm. EVIDENCE: Residents said that they felt safe living at Bystock. They said that staff treated them with respect and kindness. All staff have received training in the Protection of Vulnerable Adults. The manager and staff have worked hard to support residents to open individual bank accounts. Benefits are paid into their accounts and the home invoices residents for the fees. Residents said they enjoyed going to the Bank / Building Society. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 Not inspected on this occasion. EVIDENCE: Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 Residents are protected by the home’s recruitment practices. EVIDENCE: Recruitment files of the newest staff members were inspected and found to have the necessary information and checks to ensure that residents are well protected, including police checks. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Residents benefit from the home’s methods of monitoring its services. The health & safety of residents are well protected. EVIDENCE: The manager uses a variety of methods to monitor the quality of services that residents receive at the home. These include satisfaction questionnaires to residents, staff, relatives and professionals. Devon Community Housing Society (DCHS) have also produced a tool to assess risks throughout the home and within the services provided. Staff training and supervision are also part of the home’s quality monitoring tool along with resident / staff meetings and residents’ care plan reviews. DCHS complete a monthly unannounced visit to monitor the standards of care in the home. A report is completed and a copy is sent to the CSCI. The manager said that these visits have taken place but the CSCI have not received a copy of these reports since January 2005. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 17 The manager completes a questionnaire prior to the inspection. This provides conformation that relevant and appropriate polices and procedures are in place and have been updated. This ensures that staff and residents’ welfare and safety are protected. The fire logbook was found to be up to date and accurate and included relevant staff fire training. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x 3 x 3 x Standard No 31 32 33 34 35 36 Score x x x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bystock Court Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 26 Requirement Visits under paragraph (2) of Regulation 26 shall take place at least once a month and shall be unannounced. (C) prepare a written report on the conduct of the home. (5) The registered provider shall supply a copy of the report required to be made under paragraph (4) (c) to the Commission. Timescale for action 11/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations Medication that is not prescribed should be labelled for who it is intended and included in the homes Homely Remedy Policies. Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Suite 1, Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bystock Court D54 D06 S21897 Bystock Court V224686 090805 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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